Tuesday, August 24, 2010

Liar, Liar

We have been seeing a young man with escalating frequency for several years for breakthrough migraines; he is always brought in by his father, who is aggressive and impatient. He berates the staff if his darling boy has to wait his turn or is not seen ahead of chest paineurs, individuals with difficulty breathing or other mundane complaints such as diabetic emergencies. The kid is polite but suffers from the father's bad behavior; Daddy is a doorway-leaner and hallway stalker, frequently interrupting us by demanding to see the doctor and telling us how much pain the kid is having. Therefore,we keep them in the waiting room, bringing them to a treatment room at the last minute when we are sure the doctor is ready to see them, and not one minute before. The father has only himnself to blame.

I noticed that his visits in the last year were actually down; only 6 or 7 compared to the 22 visits the previous year. I realized that the kid had been away at college and his ER visits coincided with Winter, Spring and Summer breaks. Interesting, yes?

Demerol was the kids usual poison until we stopped stocking it. Now he gets one shot of morphine and is immediately sent home. Every case is different, of course, but this is how most of the frequent migraineurs are treated; they are told up front that we give them one shot, then it is out the door. It is their responsibility to follow up with their provider for definitive long-term management of their chronic problem. We have learned not to sit on these because it always turns into a tug of war. Give a shot of narcotic, wait 30 minutes (usually while they sleep), wake them up for vital signs, "pain still 20/10", start an IV, give them a liter of saline and more narcotics, etc, etc,. Generally after a couple of hours the docs will get tired of it, give them just one more med and send them home to sleep it off. An argument always ensues because their pain is not completely gone. This just sucks the life out us, drains our energy, and often our last remaing reserves of compassion. It is best for the patient and for us to be clear on what the patient can expect, disabusing them of the notion that what they want is not necessarily what they will get; this is especially important when the expectation is enough narcotics to easily tranquilize a bull moose.

On this particular day we were working with the Talker. He is a great doc; he loves to spend lots of quality time teaching. His sincerity and genuine caring is apparent; he does not automatically give the patient what they want and/or thinks they need, and is very patient with the Web MD self-diagnosticians. He does not automatically xray every boo boo that walks through the door, even though the patient expects it. He does a careful exam, and if the mechanism of injury does not warrant, he will not expose the patient to radiation needlessly just because they think they should have it. He spends lots of time talking about ibuprofen, ice, elevation, etc. He spends lots of time with his patients in general, and many ask if he has a private practice because he listens. I love to work with him because I always learn something new. Also, because his goal is always good medical care and not necessarily good customer service it makes me think a little before I just order patient tests before the patient is seen by the doc. Thinking, "What would the Talker do?" frequently guides my decisions; also common sense.

The young man with the migraine came in alone for this visit, which was really unusual. He was seen and examined promptly because 1) it wasn't busy and 2) his annoying father was not present. After the Talker spent about 15 minutes, the patient received morphine. He assured us that his father was in the car waiting, which was proven to be a lie since he was observed getting into the drivers side and driving off.

But he had left his wallet behind; a call to the boys home was answered by the father, who said the kid was at work. We told him that the Talker would like a word with his son when he had the chance.